ED pharmacy program has safety, quality, and cost savings benefits

Reduction in drug use saves $3 million

An Illinois hospital has shown that it can save considerable money and improve safety and quality outcomes by having pharmacists cover its emergency department (ED).

The program has helped reduce medication errors by 70% and improve clinical outcomes for patients with congestive heart failure (CHF), says James Jensen, BS, PharmD, emergency department clinical coordinator for Advocate Christ Medical Center in Oak Lawn, IL.

For example, the improved safety largely is the result of pharmacists' involvement in implementing safety initiatives, including using smart pump technology and putting alerts in the automated dispensing cabinets.

"We have a drug cabinet called Omnicell, and when nurses pull certain medications, we have a how-to pop-up on the computer screen that they have to read before they can take out the medications," Jensen explains.

Pharmacists can program these messages and add new alerts as needed.

The main goal for CHF patients was to achieve a 20% drop in their arterial blood pressure through correct titration of nitroglycerin. Once the pharmacist got involved, the ED reached this goal, Jensen says.

Another positive outcome involved improved antibiotic administration. Prior to having an ED pharmacist, it was not uncommon to have pneumonia patients who were not given antibiotic treatment for more than 6 hours after presenting in the ED, he says.

An ED clinician might have missed a chest X-ray, or nurses were backed up with difficult cases and hadn't gotten back to the patient to administer antibiotics. Once pharmacists began to work in the ED, all pneumonia patients received antibiotic treatment within 6 hours of presentation in the ED, Jensen says.

There also has been cost avoidance for the hospital since the ED's use of drugs has decreased with pharmacist participation.

In 2005 and 2006 when the first pharmacist began to work in the ED, the cost avoidance was more than $1 million. In 2007, the hospital added a second pharmacist position, which increased the total cost avoidance to more than $3 million.

Now the ED has three pharmacists who provide 16-hour coverage from Monday through Friday and 10-hour coverage on Saturdays and Sundays. And there are plans to add another pharmacist to cover a midnight shift, Jensen says.

Also, the ED pharmacy program includes a pharmacist residency for first-year and second-year residents. And there's an elective, 2-week rotation available to medical residents who might be interested in learning more about pharmacy and drug interactions, he says.

"They can work with me for 2 weeks and see the pharmacy side of things," he adds. "We probably get a couple medical residents who rotate with us each year."

Pharmacists in the ED also have developed and annually review protocols for handling patients with CHF, ischemic and hemorrhagic stroke, acute coronary syndrome, diabetic ketoacidosis, and sepsis.

Physicians and nurses use the protocols when these patients are admitted and follow the protocol guidelines for drug administration and dosing. The protocols are in paper format, but they'll soon be in electronic format, Jensen says.

The forms are kept at the nurses station where they're pulled and then filled out and signed by physicians. Nurses and doctors check the forms to note any potential medication contraindications, and they use these to verify recommended dosing levels.

"We help carry out the medication orders from the protocols," Jensen says. "And we check lab results."

Jensen describes how a typical day in the ED might unfold for a clinical pharmacist:

• Review cases where patients who have been waiting for a long time: "Usually when I come in there are patients who have been waiting in the ED for results," Jensen says. "On bad days they might be waiting for beds for 20 hours or so."

Jensen reviews why these patients are in the ED, what they're being treated for, and he sees if there are any treatment adjustments that should be made. For instance, patients who have been in the ED for a long time might need another administration of their medication.

"I discuss with the doctor their dosing — whether it's antibiotics, steroids, asthma drugs, or medication for chronic obstructive pulmonary disease exacerbations," Jensen explains. "And I make sure they receive the medication they need."

Pharmacists also check to see if these patients have any daily medications that need to be taken.

• Review medication histories: "We try to obtain a medication history from all patients who are admitted," Jensen says.

Nurses assist with this process of asking patients for their list of medications and calling community pharmacies to fill in the blanks.

• Help where needed:As patients arrive, ED pharmacists will help as needed in intubating patients in respiratory distress, dosing medications for sedation, and recommending appropriate therapies.

"We'll be at the bedside, helping nurses with any patients who have full or traumatic arrest, and we help with any code situations," Jensen says. "We help with resuscitating patients and cardiac stability."

ED physicians have liked having pharmacists at the bedside to serve as medication double-checks to minimize or eliminate errors, he notes.

"Doctors ask us all kinds of questions about patient's symptoms and whether these could be from medications," he says.

• Provide antibiotic therapy: ED pharmacists assist with antibiotic dosing and monitoring patients' antimicrobial medication, such as vancomycin therapy.

"We make sure these patients have an appropriate renal function for the drugs they're given, and we look at their complete blood count," Jensen says.

• Assist with transitions: "When patients are discharged from the emergency room, we help with medication education, home prescriptions, medication counseling, as well as diabetes education for patients who are discharged with insulin or a glucose meter for the first time," Jensen says.

Pharmacists also educate patients who were prescribed injectable anticoagulants and are returning home.